Overall, among patients older than 70 identified from the 2007-2014 National Inpatient Sample (NIS), CAS made up 11.9% of carotid revascularization procedures pre-CREST (2007-2010), a percentage that grew to 13.8% in the post-CREST period (2011-2014; P=0.005). Upon multivariable adjustment, the odds of receiving CAS had gone up over time (OR 1.13, 95% CI 1.00-1.28), especially for symptomatic women (OR 1.31, 95% CI 1.05-1.65).

Yet a year-by-year look at carotid revascularization trends shows that CAS peaked in 2012, accounting for 14.5% of procedures, before starting a downward trajectory that continued to 2014, according to a study published online in JAMA Neurology by Fadar Otite, MD, ScM, of the University of Miami Miller School of Medicine, and colleagues.

Action Points

It took a few years after 2010's publication of CREST (Carotid Revascularization Endarterectomy versus Stenting Trial) for clinicians to roll back their enthusiasm for carotid artery stenting (CAS) in the older population.

The new findings "are inconsistent with the results of CREST and suggest possible slow and incomplete incorporation of the trial results into clinical practice owing to interplay of a variety of factors," Otite et al wrote.

For one, they suggested, "the differential efficacy of CAS compared with CEA by age in CREST was primarily due to stroke events, but CAS technology has improved over the past decade ... It is arguable that stroke risk associated with newer devices and stenting techniques may approximate the stroke risk associated with CEA and hence positively influence CAS utilization."

It is also possible that the 2013-2014 closure of several postmarketing surveillance registries for stents had something to do with the downfall of CAS. "The Centers for Medicare & Medicaid Services in the United States will not reimburse for CAS except in patients classified as high risk or as part of a postmarketing surveillance registry," the investigators said, concluding that "reimbursement policies may also be playing a role in revascularization patterns."

Writing in an accompanying editorial, James Meschia, MD, of Mayo Clinic in Jacksonville, Florida, said: "The effects of CREST on the practice of stenting may have been muted because not everyone accepts the validity of having included perioperative MI in the primary composite endpoint, although the trial showed that perioperative MI carried significant morbidity.

Meschia pointed to the 31% increase in the odds of stenting in symptomatic women in the post-CREST period, noting that the measured periprocedural risk of stroke in CREST for this population was 7.5% for CAS and just 2.7% for CEA. Then again, "multivariable adjustment is not a substitute for a stratified analysis of CREST-eligible and -ineligible patients. Regrettably, the NIS database did not afford an opportunity for this type of analysis."

Information on why the decision between CEA and CAS was made was also lacking, the team acknowledged. Another caveat is the possibility of residual confounding in the retrospective study.

There was a total of 494,733 weighted U.S. hospital admissions in the sample of recipients of carotid revascularization who were age 70 or older.

The proportion of revascularization procedures performed in symptomatic patients went up from 9.0% in 2007 to 13.9% in 2014 (P<0.001).

Factors associated with higher odds of CAS were:

Symptomatic stenosis (OR 1.39, 95% CI 1.27-1.52)

Congestive heart failure (OR 1.48, 95% CI 1.35-1.63)

Peripheral vascular disease (OR 1.35, 95% CI 1.27-1.43)

CAS was less likely for patients with:

Comorbid hypertension (OR 0.70, 95% CI 0.66-0.74)

Smoking (OR 0.84, 95% CI 0.78-0.91)

Weekend admission (OR 0.77, 95% CI 0.68-0.88)

"Full translation of trial results into practice may take years, particularly when operators need to be persuaded rather than regulated into changing behavior," Meschia wrote. "Nationally, CAS continues to be perceived as an important option for stroke prevention. The next generation of trials of stenting in asymptomatic patients has the greatest potential to change practice."

Last Updated December 07, 2017

Otite listed no conflicts of interest.

One study co-author reported being on the executive committee of the CREST 2 and ACT I trials.

Meschia disclosed funding from the National Institute of Neurological Disorders and Stroke for his role as co-principal investigator for the CREST-2 Clinical Coordinating Center.

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